Efficacy of a new flossing intervention using a floss band for severe adhesion after digit tendon repair. Sasaki, et al. (2025) Level of Evidence: 4 Follow recommendation: 👍 (1/4 Thumbs up) Type of study: Therapeutic Topic: Tendon flossing - Exercises These two case report described a novel “flossing” intervention using a rubber compression band to manage severe tendon adhesions after hand surgery. The patients were a 30‑year‑old mechanic who experienced a flexor pollicis longus (FPL) re‑rupture and a 60‑year‑old construction worker with multiple extensor tendon repairs following trauma. In both instances, standard immobilisation and early active‑range‑of‑motion (AROM) protocols were initially applied, but progressive adhesion limited motion. Starting at eight weeks post‑operatively, a daily flossing routine was initiated. This included wrapping a rubber band around the affected joint, applying longitudinal pressure, twisting, and performing resisted AROM. Over a 16‑ to 24‑week period, the FPL patient’s total active motion (%TAM) rose from 20% to 80%, while the extensor‑tendon patient’s %TAM improved from 40% to >90%. Both patients regained functional range, returned to work, and avoided tenolysis. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, simple “flossing” exercises with compression, may help regaining range of movement in people who have had tendon repair in the hand. It is also possible that this flossing with compression simply reduced symptoms and allowed them to exercise with greater easy. Remember that the earlier we work on stiffness, the higher the chances of improving range. URL: https://doi.org/10.1177/17589983251387725 Abstract Background: Tendon adhesions after hand surgery can severely impair motion and function. Although early mobilization is preferred, re-ruptures or complex trauma cases often require immobilization, increasing the risk of adhesion. Purpose: This report presents two cases—one involving flexor pollicis longus (FPL) tendon re-rupture and another with multiple extensor tendon injuries—treated with a novel flossing intervention aimed at improving tendon gliding and soft tissue flexibility. Methods: In both cases, flossing therapy using a rubber compression band was introduced at 8 weeks postoperatively, following standard immobilization and rehabilitation protocols. Patients performed flossing exercises daily under supervised and home-based conditions. Results: The FPL case showed an improvement in %TAM from 20.8% to 83.3%, and the extensor tendon case improved from 42.9%–50% to 96.4%–98.4% over 16 weeks. Both patients regained functional range of motion and returned to work without requiring tenolysis. Importantly, these improvements occurred when flossing was paired with active range of motion (AROM) exercises, rather than by flossing alone. Conclusions: Flossing, particularly when combined with active range of motion (AROM) exercises, may be a useful adjunct to conventional therapy for managing severe adhesions after tendon repair. These case reports suggest that improvements were likely achieved through the combined effect of flossing and conventional active exercises, rather than flossing alone. Further studies are needed to determine the optimal parameters and generalizability of this technique. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Simulated effects of early menopausal bone mineral density preservation on long-term fracture risk: A feasibility study. Billington, et al. (2021) Level of Evidence: 4 Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Preventative Topic: Preventative bisphosphonates - Risk of fractures This simulated study, assess whether infrequent zoledronic acid (ZOL) infusion could reduce long‑term bone loss and fractures. Using longitudinal data from the Canadian Multicentre osteoporosis study, the authors modelled bone mass density trajectories with a single ZOL infusion followed by five‑yearly infusions at ages 50, 55 and 60. Applying the FRAX algorithm to estimate 10‑year major osteoporotic fracture (MOF) and hip fracture risks, the simulation predicted that early ZOL treatment would preserve lumbar spine, femoral neck and total hip BMD more effectively than age‑matched untreated women. This shifted most subjects into a “normal” T‑score range by age 80. This is based on the study I will release next week! Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, a single zoledronic acid infusion given at ages 50, 55, and 60, could stabilise lumbar spine and femoral neck bone mass density. If you are thinking: "Hold on, this is just a simulation study" buckle up because next week, I will share the most recent study that has been completed in real people. Make sure that you screen your patients for bone mass density. Medications and impact/heavy weight training, can have a massive impact on us and our patients! URL: https://doi.org/10.1007/s00198-021-05826-5 Abstract Summary: Prevention of early menopausal bone loss may reduce the future burden of osteoporosis. In this modelling exercise, an osteoporosis prevention strategy involving 5-year infusions of zoledronic acid, beginning early in menopause, reduced long-term fracture risk and the proportion of aging women with femoral neck densitometric osteoporosis. This strategy warrants further evaluation. Introduction: Preventing early menopausal bone loss may substantially reduce the future burden of osteoporosis. We modelled the effects of infrequent zoledronic acid infusions on long-term fracture risk. Methods: Data from the Canadian Multicentre Osteoporosis Study (CaMos) were used to determine the expected natural history of femoral neck areal bone mineral density (BMD) and fracture risk (using FRAX®) from ages 50–80 for women with no antiresorptive drug exposures. We modelled the effects of three infusions of zoledronic acid (at ages 50, 55, 60) on long-term fracture risk, assuming this intervention would preserve BMD until age 65 years, followed by losses mirroring early menopausal BMD loss. Results: At age 65, untreated women and zoledronic acid recipients had expected mean (SD) femoral neck T-scores of − 1.5(1.0) and − 0.8(1.0), 10-year major osteoporotic fracture (MOF) risks of 9.8%(5.0) and 8.0%(3.7) and hip fracture risks of 1.7%(2.4) and 0.8%(1.2), respectively. At age 80, untreated women and zoledronic acid recipients had expected femoral neck T-scores of − 1.9(0.9) and − 1.4(0.9), MOF risks of 17.9%(8.2) and 14.9%(6.4) and hip fracture risks of 6.3%(6.2) and 4.4%(4.5), respectively. The expected proportion of women with femoral neck T-score ≤ − 2.5 was 14.9% for untreated women and 3.8% for zoledronic acid recipients at age 65, increasing to 28.1% and 12.0%, respectively, at age 80. Numbers-needed-to-treat to prevent one case of densitometric osteoporosis were 9 at age 65 and 5 at age 80. Conclusion: Infrequent infusions of zoledronic acid, initiated early in menopause, are expected to reduce long-term fracture risk and result in a substantial reduction in the proportion of women with densitometric osteoporosis after age 65. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Patient-reported outcomes from supraclavicular thoracic outlet decompression. Bagdady, et al. (2025) Level of Evidence: 4 Follow recommendation:👍 (1/4 Thumbs up) Type of study: Therapeutic Topic: Neurogenic TOS - Symptoms after surgery This retrospective cohort assessed short‑term patient‑reported outcomes after supraclavicular thoracic outlet syndrome (TOS) decompression. A total of ten patients, eight women and two men were included in the study. All patients had positionally‑related neurogenic thoracic outlet syndrome confirmed by anterior scalene muscle blocks. Surgery involved soft‑tissue release with selective rib resection when indicated. Pre-surgery, patients presented with mild to moderate depression and pain catastrophising. After surgery, patients report an average of 90% reduction in pain and most could perform previously painful activities. However, 60% still experienced numbness, and two patients reported no improvement. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, surgical decompression of neurogenic thoracic outlet syndrome (TOS) can provide pain relief. However, patients who are particularly active (e.g. athletes) appear to have less than optimal outcomes. Keep in mind that with older age, the likelihood of degenerative cervical myelopathy is higher than TOS. For conservative management of TOS, a few options are available. Remember that carpal tunnel syndrome is a mimicker of TOS and should be picked up for management to be effective. URL: https://doi.org/10.1016/j.jhsg.2025.100817 Abstract Purpose: The diagnosis of neurogenic thoracic outlet syndrome is based on patient history, provocative maneuvers, and, ultimately, the successful relief of symptoms following surgical decompression. We sought to understand patient-reported outcomes after thoracic outlet decompression. Methods: All patients undergoing thoracic outlet decompression between July 2015 and July 2020 were identified from a single institutional database. Validated questionnaires including, Thoracic Outlet Syndrome Index, Short Form 20, Pain Catastrophizing Scale (PCS), Zung Self-Reporting Depression Scale, and nine of our own questions, were used to report patient outcomes from 10 individuals. Results: The Thoracic Outlet Syndrome Index, Zung Self-Reporting Depression Scale, Short Form 20 pain subscore, and PCS averages were 63 (± 44.3), 58.25 (± 5.04), 40.3 (± 17.5), and 22.6 (± 18.81), respectively. One hundred percent of patients indicated some level of depression with 50% indicating mild levels and 50% indicating moderate levels of depression. Pain was the most commonly reported improved symptom after surgery with 50% indicating a ≥95% improvement. Despite 80% of patients indicating surgery provided the results they were expecting, 60% still had some element of numbness in their arm or hand. Conclusions: Thoracic outlet decompression can produce high levels of symptom improvement, especially in regards to pain. Lack of improvement can be related to a multitude of factors including confounding depression, pain catastrophizing/neurosis, inaccurate diagnosis of thoracic outlet syndrome, or double crush syndrome. More objective tests for identifying thoracic outlet syndrome may help to better understand which patients have a better likelihood of symptom improvement after surgery. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Cubital tunnel revision after transposition: A single center experience. King, et al. (2025) Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic: Cubital tunnel - Revision surgery This retrospective study assessed the number of revision surgeris completed after cubital tunnel releases with transposition. After excluding traumatic and post‑traumatic cases, 216 primary transpositions remained. Twenty patients (3% of all releases and 9% of the transposition surgeries) required revision surgery. Revision surgery occurred on average 16 months from the primary surgery. The results showed no significant difference in revision rates among subcutaneous, subfascial, or submuscular transpositions. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, 9% of cubital tunnel releases with transposition require further revision, with the average time to revision being 16 months. It is important to set expectations in people undergoing this surgery as it appears that patients present with low satisfaction as it does not always resolve their symptoms. It is nevertheless an important surgery as people who wait longer, tend to present with worse neurological function. URL: https://doi.org/10.1016/j.jhsg.2025.100815 Abstract Purpose: The purpose of this study was to assess the rates of revision after cubital tunnel release with transposition among three different transposition techniques in a single institution. Methods: A retrospective chart review of all cubital tunnel surgeries over a 5-year period was performed via a query of the billing records of three different surgeons who typically perform three different types of transposition. This yielded 937 records. After eliminating records with incomplete clinical information (141 records), a total of 796 records were evaluated, with 540 representing in situ releases and 255 transpositions. The transposition cohort was further evaluated, and 39 records were eliminated as the operation was performed for traumatic or post-traumatic indications, leaving 216 transpositions performed between December 1, 2016, and December 1, 2021. Results: In the 216 cubital tunnel releases with transposition performed, 82 (38%) were subcutaneous transpositions, 71 (33%) were subfascial transpositions, and 63 (29%) were submuscular transpositions. Twenty of the 216 cubital tunnel releases with transpositions that were performed in this study period represented revision surgeries. Eleven were revisions after an in situ release, and eight were revisions after a transposition. One is unknown as the index operation was performed by an outside physician whose operative note was not available. Of the revision surgeries performed, 10 represented revisions of index cases performed by our institution with six being revisions for an in situ release and four revisions after a transposition. Of those four revisions after a transposition, one was performed for a subcutaneous transposition, two were following subfascial transpositions, and one was following a submuscular transposition. The average time from index operation to revision after a transposition was 16.3 months. Conclusions: The rate of revision surgery following cubital tunnel release with transposition is quite low, and there do not appear to be major differences in the rate of revision among the different types of surgical transposition, indicating that a true subcutaneous transposition may be adequate. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Biomechanical comparison of volar plate repair versus volar plate repair with suture tape augmentation at the finger proximal interphalangeal joint. Wright, et al. (2025) Level of Evidence: 4 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic: Volar plates - Repair augmentation This cadaveric study assessed whether adding suture tape augmentation to volar plate repair enhanced biomechanical stability in proximal interphalangeal joint laxity. Ten matched finger pairs from five cadavers underwent extension‑laxity testing at 5 and 10 N·cm, followed by a standardised volar‑plate release and 30° hyperextension injury. Each side of a pair was repaired either with a single suture anchor (volar plate repair alone) or with the same anchor plus a 1.3 mm suture tape bridged through a second anchor (suture‑tape augmentation). Cyclic loading (2–5 N·cm, 30 cycles) and subsequent load‑to‑failure testing were performed. Both repairs reduced extension laxity relative to injury, but the augmented construct displayed significantly greater stiffness at 10, 20, and 30 cycles, higher yield load (16.7 vs 12.4 N·cm), greater ultimate load (25.9 vs 19.1 N·cm), and absorbed more energy at failure. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, suture tape augmentation significantly improves the volar‑plate repair resilience. We know that pipj volar plate repairs work, if you have an athlete that needs to return to sport quickly, maybe you could suggest this approach to the surgeon! If they do not want surgery, you can provide them with an oval 8, and remember, they don't need to be placed in pipj flexion for the volar plate to heal. URL: https://doi.org/10.1016/j.jhsa.2024.11.005 Abstract Purpose: The purpose of this study was to perform a biomechanical comparison of volar plate repair alone versus volar plate repair with suture tape augmentation in a hyperextension laxity injury model at the proximal interphalangeal (PIP) joint. Methods: Ten matched cadaveric fingers were obtained from five cadavers (average age, 59 ± 7 years). The specimens underwent 5 and 10 N·cm of extension load at the PIP joint to measure the laxity of the intact joint. Next, an injury model was created by incising the proximal volar plate and loading the specimen on a testing machine to 30° of hyperextension; laxity testing was repeated. Within each matched pair, one side was used for volar plate repair, and the contralateral side was used for volar plate repair with suture tape augmentation. Laxity measurements were repeated. The specimens were then loaded from 2 to 5 N·cm for 30 cycles, and then loaded to failure. Results: In both groups, extension angle significantly increased following PIP joint injury. Both repair groups significantly decreased extension angle compared with injury. Specimens that underwent volar plate repair with suture tape augmentation demonstrated significantly increased stiffness at 10, 20, and 30 cycles compared with volar plate repair alone (3.4, 3.5, and 3.6 N·cm/° vs 2.5, 2.5, and 2.6 N·cm/°, respectively), a higher yield load (16.7 vs 12.4 N·cm), and ultimate load (25.9 vs 19.1 N·cm) and absorbed more energy at ultimate load (4.1 vs 2.6 N·cm). Conclusions: Suture tape augmentation increased construct stiffness, yield load, load to failure, and ultimate load in this biomechanical study and may offer additional support in volar plate repair for chronic PIP joint hyperextension laxity. Clinical relevance: This finding lends support to using suture tape as an augment to produce a stronger PIP joint repair, potentially leading to an expedited recovery and earlier return to activities. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Nonoperative versus operative treatment for displaced finger metacarpal shaft fractures. Peyronson, et al. (2023) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic, Economic and Decision Analyses Topic: Displaced metacarpal #s - Return to work This randomised controlled trial compared nonoperative versus operative management of displaced finger metacarpal shaft fractures in 42 adults (22 treated nonoperatively and 20 operatively) and evaluated outcomes at 12 months. The primary outcome, hand grip strength, showed no significant difference between groups. Secondary outcomes including DASH scores, pain, patient satisfaction, and range of motion were also comparable, while the nonoperative group experienced markedly less metacarpal shortening and a significantly shorter duration of sick leave. Operative treatment incurred higher costs and a 15 % complication rate, versus no complications in the nonoperative cohort. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, nonoperative treatment of displaced metacarpal shaft fractures gives grip strength, DASH scores, pain, and ROM comparable to surgery at 12 months, while reducing shortening, sick‑leave duration, costs, and complications. If you want to provide something supportive for their return to work, a clam shell splint over rigid casting could be useful. We can also reassure patients that functional outcomes are not compromised and that the are likely to have similar outcomes to a surgical approach. These findings are in line with previous research suggesting that a hand based cast/splint are sufficient. URL: https://doi.org/10.2106/JBJS.22.00573 Abstract Background: Finger metacarpal fractures represent up to 31% of all hand fractures, and most can be treated nonoperatively. Whether operative treatment is superior to nonoperative treatment for oblique and/or spiral finger metacarpal shaft fractures (MSFs) is unknown. Methods: Forty-two patients with displaced oblique and/or spiral finger MSFs were randomized to either nonoperative treatment with unrestricted mobilization or operative treatment with screw fixation. The primary outcome was grip strength in the injured hand compared with the uninjured hand at the 1-year follow-up. Secondary outcomes were the Disabilities of the Arm, Shoulder and Hand score, range of motion, metacarpal shortening, complications, sick leave duration, patient satisfaction, and costs. Results: All patients attended the 1-year follow-up. Mean grip strength relative to that in the contralateral hand was 104% (95% confidence interval [CI], 89% to 120%) in the nonoperative group and 96% (95% CI, 89% to 103%) in the operative group (p = 0.34). Mean metacarpal shortening was 5.3 mm (95% CI, 4.2 to 6.4 mm) in the nonoperative group and 2.3 mm (95% CI, 0.8 to 3.9 mm) in the operative group. In the nonoperative group, 1 minor complication was observed; in the operative group, there were 4 minor complications and 3 reoperations. The costs were estimated at 1,347 U.S. dollars (USD) for nonoperative treatment compared with 3,834 USD for operative treatment. Sick leave duration was significantly shorter in the nonoperative group (12 days [95% CI, 5 to 21 days] versus 35 days [95% CI, 20 to 54 days]) (p = 0.008). Conclusions: When treated with unrestricted mobilization, patients with a single displaced spiral and/or oblique finger MSF have outcomes comparable to those treated operatively, despite metacarpal shortening. Costs are substantially higher (2.8 times) and sick leave is significantly higher in the operative group. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Postoperative treatment of proximal humerus fractures with an early active motion protocol: A prospective randomized controlled trail. Crepaz-Eger, et al. (2025) Level of Evidence: 2a Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic: Early mobilisation - Proximal humerus ORIF This randomised controlled trial assessed whether an early active‑motion protocol was non‑inferior to a conventional sling‑based regimen after locking‑plate fixation of proximal humerus fractures. A total of 40 were randomised to either a 4‑week immobilization group (CG) or an unrestricted movement group (EXP). All participants received the same surgical technique (an ORIF with plate) and were followed for 24 months. Primary outcomes were the Disabilities of the Arm, Shoulder and Hand (DASH) score, while secondary measures including pain (VAS), and patient satisfaction. Results showed no significant differences between groups on the DASH 16 vs. 14. Pain and satisfaction scores were comparable, and complication rates were 30% for CG and 15% for EXP. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, proximal humerus fractures ORIF can safely commence an unrestricted, early active‑motion program without compromising functional recovery compared with the traditional 4‑week sling‑based approach. Over a 24‑month follow‑up, both groups achieved comparable functional and symptoms outcomes. Keep in mind that in patients over 60, you can conservatively manage this fractures without surgery and the outcome are equivalent. Remember to always screen patients for reduced bone mass density and refer them on for treatment if they are osteopenic. URL: https://doi.org/10.1016/j.jse.2025.01.042 Abstract Background: Proximal humerus fractures are common injuries in elderly patients. Although a majority of fractures can be treated conservatively, open reduction and internal fixation (ORIF) with locking plates is still the most commonly used operative treatment modality. Regarding postoperative treatment, there is currently no consensus in the literature. A restrictive rehabilitation regimen, which can lead to a prolonged and effortful rehabilitation process, may not make full use of the possibilities that modern angular stable implants in combination with adequate patient selection and improved operative techniques have to offer. Therefore, this study aimed to investigate the functional results of a novel early active motion rehabilitation protocol for postoperative treatment of proximal humerus fractures treated with a locking plate. Methods: From March 1, 2016, to February 29, 2023, patients were prospectively screened for inclusion. In the conventional group (CG), patients underwent a strict postoperative protocol with immobilization in a shoulder-arm sling for 4 weeks, which should be worn day and night. In the early functional group (EFG), no restrictions regarding movement and force were given. In both groups, no heavy lifting, no exhausting physical activity, and no blunt force on the arm was performed for 3 months postoperatively. Within a follow-up of 24 months, primary and secondary outcome parameters were collected. Results: No significant difference was found in the Disabilities of the Arm, Shoulder and Hand (DASH) score, Constant score (CS), and relative CS for the injured shoulder at any point of observation. After 24 months, the CS showed a mean of 81.3 (standard deviation [SD] 11.6) points in the CG and 78.4 (SD 14.0) points in the EFG. Relative CS was 89.8% of the uninjured side in both groups, respectively. DASH score showed a mean of 15.9 (SD 15.8) in the CG and 13.9 (SD 15.2) in the EFG. There was also no significant difference in visual analog pain scale score, patient satisfaction, and EuroQol–5 Dimensions visual analog scale score in between the groups. Conclusion: It could be demonstrated that early active motion rehabilitation for postoperative treatment after locking plate fixation of proximal humerus fractures was not inferior to a restrictive treatment protocol after a follow-up period of 24 months, even in a slightly older and more comorbid patient population. Further studies investigating postoperative rehabilitation after ORIF of proximal humerus fractures should be conducted. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Nonsurgical treatment versus surgical treatment in displaced metacarpal spiral fractures: Extended 4.5-year follow-up of a previously randomized controlled trial. Peyronson, et al. (2025) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic: Displaced metacarpal spiral fracture - Non surgical approach This is a secondary analysis of a randomised controlled trial assessing assessing long term outcomes of conservative vs surgical management of displaced metacarpal spiral fracture without scissoring. Outcomes were measured at 4.5‑year after randomisation in 34 patients. Participants were included if they had a single displaced spiral or oblique metacarpal shaft fracture of the 2nd, 3rd, 4th, or 5th metacarpal. The outcome of interest was grip strength and the non-inferiority margin was 15% of the unaffected side. Secondary outcome measures included the DASH score, range of motion, rotational deformity, and pain. The results showed that conservative treatment was non-inferior to surgical management. There was no difference between the groups in the secondary outcomes. The blue bar represents two-sided 95% CI for grip strength percentage in the nonsurgical group versus noninferiority margin (
15% represented by the dotted yellow line). The green bar represents two-sided 95% CI for grip strength percentage in the nonsurgical group adjusted for hand dominance. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, at long term follow up (4.5 years) there is no difference in grip strength/function/pain in people who were managed conservatively or surgically after a single‑ray displaced metacarpal spiral fracture without scissoring. This is additional evidence suggesting that metacarpal fractures can be managed conservatively in most cases. Such approach can be extended to proximal phalanx unstable fractures, especially if the patient is not keen to undergo surgery. More information on the conservative management of single‑ray displaced metacarpal spiral fracture without scissoring next week! URL: https://doi.org/10.1016/j.jhsa.2025.06.018 Abstract Purpose: Spiral or oblique fractures of the metacarpals of rays II−V are common and often managed nonsurgically. Surgery is typically recommended for fractures with displacement or rotational deformity. In a recent randomized controlled trial of displaced fractures, nonsurgical treatment with early unrestricted mobilization was found to be noninferior to surgical treatment at the 1-year follow-up. However, long-term outcomes comparing these approaches have not been reported. This study evaluated whether treatment differences emerge at the midterm follow-up, hypothesizing that nonsurgical treatment will remain noninferior. Methods: Of 42 patients with displaced spiral/oblique metacarpal shaft fractures enrolled in our previous randomized controlled trial, 34 were analyzed at a mean of 4.5 years postinjury (range: 3.1–6.6 years). The primary outcome was grip strength of the injured hand relative to the uninjured hand, with and without adjustment for hand dominance. Secondary outcomes included the Disabilities of the Arm, Shoulder, and Hand score, range of motion, rotational deformity, complications, and patient-rated pain. Results: Nonsurgical treatment remained noninferior within the predefined margin. The mean grip strength was 95% of the uninjured hand in the nonsurgical group and 95% in the surgical group. After adjusting for hand dominance, the mean grip strength was 103% of the uninjured hand in the nonsurgical group and 96% in the surgical group. Secondary outcomes were similar between the groups. Conclusions: Nonsurgical treatment with early unrestricted mobilization remains noninferior to surgical treatment at the midterm follow-up. These findings support the viability of this treatment option for displaced single spiral or oblique metacarpal shaft fractures of rays II–V in patients who prefer nonsurgical treatment. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Childhood trauma, ptsd/cptsd and chronic pain: A systematic review. Karimov-Zwienenberg, et al. (2024) Level of Evidence: 2a Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Aetiologic, Prognostic Topic: Childhood trauma - Adulthood persistent pain This systematic review examined the interplay between childhood trauma, PTSD, and chronic pain in adults. Thirteen studies were included in the review. The results showed that neglect and emotional abuse were significant risk factors for chronic pain conditions, particularly fibromyalgia. Higher cumulative childhood maltreatment was associated with dose‑responsive increases in PTSD symptoms, re‑traumatisation, and perceived distress in later life, underscoring the long‑term burden of early adverse experiences. Neurophysiological findings showed altered pain modulation in patients with PTSD, suggesting differential hypo‑ and hyper‑responsivity. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, a happy childhood is protective for persistent pain in adulthood. Childhood trauma can both dampen and amplify nociceptive signalling leading to allodynia and hyperalgesia. As we know, pain is a brain output that is not only influenced by nociceptive inputs but also by peripheral and central factors that carry a history with them rather than being deterministically. If you get a chance, read Behave by Robert Sapolsky. It will boost your understanding of patients. URL: https://doi.org/10.1371/journal.pone.0309332 Abstract Background: Despite the growing body of literature on posttraumatic stress disorder (PTSD) and chronic pain comorbidity, studies taking into account the role of childhood exposure to traumatic and adverse events remains minimal. Additionally, it has been well established that survivors of childhood trauma may develop more complex reactions that extend beyond those observed in PTSD, typically categorized as complex trauma or CPTSD. Given the recent introduction of CPTSD within diagnostic nomenclature, the aim of the present study is to describe associations between childhood trauma in relation to PTSD/CPTSD and pain outcomes in adults with chronic pain. Methods: Following PRSIMA guidelines, a systematic review was performed using the databases Pubmed, PsychInfo, Psychology and Behavioral Sciences Collection, and Web of Science. Articles in English or French that reported on childhood trauma, PTSD/CPTSD and pain outcomes in individuals with chronic pain were included. Titles and abstracts were screened by two authors independently and full texts were consequently evaluated and assessed on methodological quality using JBI checklist tools. Study design and sample characteristics, childhood trauma, PTSD/CPTSD, pain outcomes as well as author’s recommendations for scientific research and clinical practice were extracted for analyses. Results: Of the initial 295 search records, 13 studies were included in this review. Only four studies explicitly assessed links between trauma factors and pain symptoms in individuals with chronic pain. Findings highlight the long-term and complex impact of cumulative childhood maltreatment (e.g., abuse and neglect) on both PTSD/CPTSD and chronic pain outcomes in adulthood. Conclusion: This review contributes to current conceptual models of PTSD and chronic pain comorbidity, while adding to the role of childhood trauma and CPTSD. The need for clinical and translational pain research is emphasized to further support specialized PTSD/CPTSD treatment as well as trauma-informed pain management in routine care. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Digital doses: Virtual reality use for perioperative pain and anxiety in patients undergoing hand surgery. Xiao, et al. (2025) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic: VR - Hand surgery This was a randomised controlled trial assessing whether immersive virtual reality (VR) could serve as a non‑pharmacologic adjunct during minor hand surgery performed under local anaesthesia. A total of 40 patients scheduled for elective hand procedures (e.g. carpal tunnel/trigger finger release) were randomised to standard monitored anesthesia care (MAC) alone or to MAC plus a VR headset providing immersive environments. Pain and anxiety were measured with numeric rating and anxiety scales, while intra‑operative medication usage and vital signs were recorded. Although VR did not produce statistically significant differences in self‑reported pain or anxiety at any time point, patients receiving VR required significantly less intra‑operative midazolam and fentanyl, and a multivariable analysis confirmed VR as a significant predictor of reduced anxiolytic use. Physiologic parameters remained comparable between groups, and VR recipients reported high satisfaction and relaxation, with 85 % believing the technology improved their surgical experience. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, immersive virtual reality worn during hand surgery under local anesthesia markedly lowers intra‑operative sedative and opioid consumption. Patients also report high satisfaction and a perception that the experience improved their surgical experience. There is growing evidence that virtual reality is useful for upper limb rehab and it may become more widespread once the costs abate. URL: https://doi.org/10.1016/j.jhsg.2025.100830 Abstract Purpose: Virtual reality (VR) is increasingly recognized as a complementary tool to address pain and anxiety. We conducted a randomized controlled trial to evaluate the effectiveness of VR for the management of pain and anxiety in patients undergoing minor hand surgery. Methods: Patients undergoing outpatient hand surgery were randomized to VR or control groups. In addition to the standard anesthetic protocol, the VR group received a VR experience as part of their preoperative care. Patient anxiety and pain scores were collected using the Numerical Visual Analog Anxiety Scale and Numerical Rating Scale, respectively. In addition, we recorded changes in patient hemodynamics and any additional medication doses required to manage pain or anxiety. Results: Forty-one patients (21 VR and 20 control) were enrolled. There were no differences in reported pain or anxiety scores before, during, or after surgery. There was no difference in vital signs or recovery times. Patients in the VR groups received less additional midazolam (0.4 mg vs 1.2 mg) and fentanyl (10 mcg vs 27.4 mcg) compared with patients in the control group. In a multivariable model, VR use remained the only significant predictor for no required midazolam. Eighty-five percent of patients believed that the use of VR positively impacted their surgical experience. As a result of the VR experience, 78% believed that their anxiety decreased and 61.1% believed that their pain decreased. Conclusions: Although patient pain and anxiety levels between the VR and non-VR groups were similar, the VR group required significantly less midazolam and fentanyl. Moreover, VR use was the only predictor of not requiring midazolam administration during surgery. Patient satisfaction was high with VR usage. VR implementation during minor hand surgery is a viable option to improve patient experience. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Comparative clinical outcomes and patient satisfaction in primary vs. Revision total elbow arthroplasty. Ryu, et al. (2025) Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Symptoms prevalence Topic: Elbow revision arthroplasty - Are patients still happy? This retrospective cohort study assessed outcomes and satisfaction of people undergoing primary total elbow arthroplasty (TEA) and revision arthroplasty. A total of 51 participants, 33 TEA and 18 revisions with a minimum follow up of 2 years, were included in the present study. Outcomes measured included the Mayo Elbow Performance Score (MEPS), Disability of the Arm, Shoulder and Hand (DASH) questionnaire, and flexion‑extension range of motion. The revision group presented with clinically significant lower levels of function (e.g. DASH 54 vs 33), worse ROM (108° vs 86°). Interestingly, patient satisfaction scores did not differ between TEA and revision groups. Representative case of a patient with aseptic loosening. (A) A 71-year-old female patient presented with early humeral component loosening 1.5 years after primary TEA surgery. A cortical thinning balloon-like expansion was observed on X-ray. component loosening 1.5 years after primary TEA surgery. A cortical thinning balloon-like expansion was observed on X-ray. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, despite revision total elbow arthroplasties achieving worse functional and range of movement outcomes (compared to first time arthroplasty), patients' overall satisfaction is high. This suggests that patients adjust their expectations after a failed primary procedure and their satisfaction may reflect relief from uncertainty/some improvement rather than absolute function. For us clinicians, it is a good reminder that absolute metrics can be independent from patients' priorities. In a similar fashion, surgeries which are extremely helpful in preventing further neurological impairment in people, can be perceived as providing little satisfaction in the patients' eyes (e.g. cubital tunnel release). Good communication on expectations and reasons for intervention are extremely important. URL: https://doi.org/10.1016/j.jse.2025.01.036 Abstract Background: Total elbow arthroplasty has become a common surgical procedure. However, a certain percentage of patients may require revision due to unsatisfactory outcomes or complications. This study aimed to compare the clinical outcomes and patient satisfaction between primary and revision total elbow arthroplasty (TEA), considering factors such as etiology and causes for revision. Methods: The study utilized a retrospective analysis of medical records from a cohort of 33 and 18 cases of primary and revision TEA, respectively, with a minimum follow-up of 2 years from the primary procedure. Clinical outcomes were assessed by measuring the Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand score, range of motion, numeric rating scale, the Single Assessment Numeric Evaluation questionnaire, and patient satisfaction. Results: Significant differences were observed between primary and revision groups in the Mayo Elbow Performance Score (79.5 vs. 65.0), Disabilities of the Arm, Shoulder and Hand scores (32.6 vs. 53.7), and elbow range of motion (107.6° vs. 85.8°). The patients' subjective assessment via the numeric rating scale score, Single Assessment Numeric Evaluation score, and satisfaction did not show significant differences. The average numeric rating scale score was 1.6 for both groups; however, the Single Assessment Numeric Evaluation score (63 vs. 54) and patient satisfaction (4.0 vs. 4.1) were not significantly different between groups. Conclusion: The clinical outcomes of primary vs. revision TEA were significantly worse in the revision group. Patient satisfaction scores were not different between the primary and revision groups despite differences in outcome scores, suggesting that revision patients may be satisfied with their outcomes despite lower clinical scores. These findings underscore the importance of considering both patient-reported outcomes and satisfaction levels in addition to objective clinical measures when evaluating the success of primary vs. revision TEA procedures. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Complex regional pain syndrome: advances in epidemiology, pathophysiology, diagnosis, and treatment. Ferraro, et al. (2024) Level of Evidence: 2a Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Aetiologic/Therapeutic Topic: CRPS - Immunotherapy This is a systematic review on Complex Regional Pain Syndrome (CRPS). Current evidence indicates that while many patients experience rapid improvement within the first six months, a substantial proportion (15-30%) continue to meet diagnostic criteria beyond 12–18 months, with persistent pain, sensory disturbances, and functional impairment being common. Return‑to‑work rates are low, underscoring the substantial socioeconomic burden. Pathophysiological investigations suggest that immune dysregulation, autoantibodies, and inflammatory cytokines may play key roles, yet definitive therapeutic targets are lacking. Diagnostic criteria are still debated, and the clinical heterogeneity hampers treatment selection. Existing interventions from pharmacological agents such as low‑dose naltrexone and vitamin C to multimodal rehabilitation and neuromodulation have uncertain efficacy and safety profiles. Future research priorities include accurate epidemiological estimates, validation of risk prediction models, exploration of immune mechanisms, refinement of diagnostic coding, and development of tailored, mechanism‑based therapies that incorporate patient preferences throughout the research cycle. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, complex regional pain syndrome (CRPS) has a high probability of improvement within the first six months from injury. However, 15-30% of people continue to suffer pain, sensory changes, and functional loss beyond a year. Prevention of CRPS is the best option at this stage and we know that making sure that a cast/splint is comfortable, limit the imobilisation period to what is absolutely necessary, strongly encourage patients to take their painkillers, and consider vitamin C supplementation are all simple and effective approaches in reducing the incidence of CRPS. Unfortunately, some people are genetically predisposed (30% of people with CRSP) and they are probably more likely to develop CRPS despite these preventative measures. If despite our preventative measures and rehab people still develop CRPS, byphosponate infusion at 4 months from onset may be useful. This could also help prevent future fractures in this group of people as shown by the effect of infrequent zelodronate infusions, a synopsis will cover this in the near future. URL: https://doi.org/10.1016/s1474-4422(24)00076-0 Abstract Complex regional pain syndrome (CRPS) is a rare pain disorder that usually occurs in a limb after trauma. The features of this disorder include severe pain and sensory, autonomic, motor, and trophic abnormalities. Research from the past decade has offered new insights into CRPS epidemiology, pathophysiology, diagnosis, and treatment. Early identification of individuals at high risk of CRPS is improving, with several risk factors established and some others identified in prospective studies during the past 5 years. Better understanding of the pathophysiological mechanisms of CRPS has led to its classification as a chronic primary pain disorder, and subtypes of CRPS have been updated. Procedures for diagnosis have also been clarified. Although effective treatment of CRPS remains a challenge, evidence-based integrated management approaches provide new opportunities to improve patient care. Further advances in diagnosis and treatment of CRPS will require coordinated, international multicentre initiatives. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings